Hepatitis A Among People Who Use Drugs and Are Homeless: West Virginia's 2018 Outbreak

In March 2018, the Kanawha-Charleston Health Department (KCHD) in West Virginia began investigating a cluster of hepatitis A virus (HAV) infections. CDC tests on 12 specimens found genotype 1B — the strain behind outbreaks in several states, mainly among people who use drugs and people experiencing homelessness. With cases still coming in, the state's Bureau of Public Health asked CDC for help in August 2018.

The cases

Looking back, KCHD identified 664 outbreak cases from January 1 to August 28, 2018.

How it spread

Hepatitis A is usually shed in stool and spreads by the fecal-oral route — through direct contact between people or through contaminated food or water. Here it spread mainly from person to person among people who used drugs, injected or not.

Vaccination

Hepatitis A is vaccine-preventable, and vaccination is the main way to stop an outbreak.

Statewide, from August 2018:

• vaccination at four regional jails;
• through harm reduction programs and a large drug treatment center;
• vaccination toolkits for 40 federally qualified health centers.

In Kanawha County, KCHD targeted people at high risk:

• opt-out vaccination on entry to homeless shelters;
• vaccination at meal centers, drop-in centers and other places serving homeless people;
• through emergency medical services, vaccination of people who used drugs and close contacts of confirmed cases.

Maps of cases and of adult vaccinations guided where to go next.

By February 2019, the statewide outbreak was still going — 74 new cases in January — but fewer than five were in Kanawha County.

Lessons

Other states with similar outbreaks have reached people at risk by vaccinating in emergency departments, syringe exchange programs, jails and drug treatment facilities. Raising vaccination among high-risk groups, as the Advisory Committee on Immunization Practices recommends, can slow outbreaks and prevent new ones — and offering the vaccine at every point of contact with health and service providers can help.

Sources

Based on Wilson E, Hofmeister MG, McBee S, et al., "Notes from the Field: Hepatitis A Outbreak Associated with Drug Use and Homelessness — West Virginia, 2018," MMWR volume 68, number 14, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report gives the one death as 0.1% of cases, which it is not, so only the count is given.